BRITISH MEBICAL JOURNAL
21 FEBRUARY 1976
weakness in any other muscle groups. Two separate Tensilon tests (10 mg edrophonium chloride) wvith saline control were performed in a double-blind manner. After the first injection of edrophonium chloride the ptosis improved greatly, and two days later with the second test the improvement was less marked. After the Tensilon tests all therapy was stopped and the patient referred to the late Professor Andrew Wilson, who suggested that this myasthenic syndrome might be related to the practolol. Electromyography revealed no abnormality, nor did it six months later, when the patient had been off all therapy. Investigations including ESR, haemoglobin, blood urea and electrolytes, thyroid function tests, and x-rays of the mediastinum revealed no abnormality. The myasthenic symptoms have not recurred following the second dose of edrophonium chloride, but because the patient's blood pressure rose after stopping the practolol he was restarted on spironolactone 100 mg daily and bendrofluazide 5 mg daily.
461
Dukes classification stage A is a tumour limited to the submucosa, B is with invasion through the muscularis without nodal metastasis, and C with spread to the nodes." With regard to group A and to some extent also to group B this seems to be wrong. In the original article' and later papers and monographs by Dukes2 3 the definitions given are: in group A cases the growth is limited to the rectal wall (also including cases infiltrating into but not outside the muscularis propria); in group B the growth has infiltrated into the perirectal tissue but has not reached the regional lymph nodes; and in group C there are metastases in the lymph nodes. These groups are well illustrated by Dukes in the original paper and later articles. As the Dukes classification for cancer of the large bowel is used world-wide it seems most important that workers in this field, in stating that this classification has been used, should adhere to the definition given by Dukes himself to ensure as strict comparability of material and results as possible.
As remission may occur in myasthenia gravis perhaps a three-year follow-up period is too short to be sure that relapse will not occur. However, as the principal adverse effects associated with the use of practolol affect the eyes, skin, aural and nasal mucous membranes, CLAS G LINDSTROM and mesentery (14 June, p 577) and we have seen no mention of a muscular syndrome, we University Department of Pathology, General Hospital, feel it worth alerting clinicians to the possibility Malmo, Sweden of this syndrome being associated with practolol. Dukes, C E, 7lournial of Pathology anzd Bacteriology, 1932, 35, 323. R OSBORNE HUGHES 2 Dukes, C E, 7ournzal of Pathology antid Bacteriology, F J ZACHARIAS 1940, 50, 527. 3
Clatterbridge Hospital, Bebington, Wirral, Merseyside
Dukes. C E, Cancer of the Rectumsz, p 66. Edinburgh and
London, Livingstone, 1960.
***Dr Lindstrom is quite right; we quoted a widely used American version of the Dukes classification which, as he points out, is An unnecessary risk to children inaccurate. We agree that the definitions originally proposed by Dukes should be SIR,-While I have considerable sympathy retained for international use.-ED, BMJ. with the general contention that children should remain in the back seat- (leading article, 24 January, p 180). in the present state of the law on seat belt equipment this may serve Folic acid deficiency during intensive actually to increase the incidence of death and therapy injury rather than reduce it. This arises because less than 1 of cars have seat belts in SIR,-We have followed the recent papers on the rear seat, since they are not a mandatory this subject1 2 and the ensuing correspondrequirement, and children between the ages of ence;-- with great interest. Ibbotson et a14 8 and 14 rarely use the child type of harness, point out that we did not state the exact type In these circumstances it is quite conceivable of intravenous nutrition in our paper" and so that it is safer to be in the front seat belted up we have now received our two cases. The first than in the back seat unbelted. patient, who had a short illness following While the article quoted some statistics, mitral valve replacement, received saline and these were not on a comparative basis. In par- dextrose only, while the second, who had ticular, the extent to which the front seat risk septicaemia and renal failure, received Aminois higher than that for the rear and the savings sol (without ethanol) for six days in his terlikely to be brought about by the wearing of minal illness. However, circulating megaloblasts seat belts in each location. It may be that an were seen as early as 24 hours after comexpansion of your analysis would indicate that mencing this treatment. There is no evidence mandatory fitment of belts to the rear seats is that either patient received ethanol. a more beneficial proposal. Although our two cases fi-t into the syndrome It continues to be important that new legis- of rapidly developing folate deficiency during lation is reasonably likely to bring about an intensive therapy, they showed in addition improvement just as the effectiveness of new extremely bizarre features (for example, medications should be proved. Otherwise the gigantoblasts, dyserythropoietic changes, frepublic is brought into increasing conflict with quent multinucleate cells, vacuolation) superthe police for no benefit. imposed on the more usual megaloblastic J S ANDERSON changes. These additional changes may have been due to factors such as infection, drugs, Chorley, Lancs uraemia, anoxia, etc, having a direct effect on erythropoiesis. On an historical note, Ibbotson et all inDukes classification of carcinoma of the ferred from our paper that the first description rectum of this bizarre megaloblastic and dyserythropoietic anaemia of rapid onset occurring in SIR,-In your leading article (13 December, seriously ill patients was that of Limarzi and p 605) entitled "Search for presymptomatic Levinson.7 In fact we attributed this to an large bowel cancer" it is stated that "on the earlier paper by Harvier and Mallarme pub-
lished in 1938. Unfortunately this date was misprinted as 1968 in the list of references. M SAARY Department of Haematology, St Bartholomew's Hospital, London EC1
A V HOFFBRAND Department of Haematology, Royal Free Hospital, London NW3
IWardrop, C A J, et al, Lancet, 1975, 2, 640. Ibbotson, R M, Colvin, B T, and Colvin, M P, British Medical Journal, 1975, 4, 145. Wardrop, C A J, et al, British Medical Journal, 1975, 4, 344. 4Ibbotson, R M, Colvin, B T, and Colvin, M P, British Medical Journal, 1975, 4, 522. 5 Colvin, B T, and Ibbotson, R M, Journal of Clinical Pathology, 1975, 28, 1007. 6 Saary, M, et al, Journal of Clinical Pathology, 1975, 28, 324. 7Limarzi, L R, and Levinson, S A, Archives of Pathology, 1943, 36, 127. Harvier, P, and Mallarme, J, Sang, 1938, 12, 883. 2
Neonatal jaundice in association with operative delivery
SIR,-I read with interest Professor E A Friedman and Mr M R Sachtleben's paper (24 January, p 198) and their suggestion that clinically undetectable focal haemorrhage secondary to instrumental delivery might be a major contributory factor in the rising incidence of neonatal jaundice. I would like, however, to bring to their attention our findings published in August 1974.' On analysis of the full-term infants admitted to the special care unit of the Simpson Memorial Maternity Pavilion, Edinburgh, for hyperbilirubinaemia we similarly found no clear relationship with oxytocin administration, but the Kielland forceps delivery rate for the group was twice the mean for the hospital over the same period. Our conclusion was that the cumulative effects of induction plus operative vaginal delivery even near term probably produces a number of neonates not totally prepared for extrauterine life. In particular their hepatic conjugating mechanism might remain untriggered. We felt that focal haemorrhage too small to be clinically detected was unlikely to elevate the serum bilirubin concentration to such levels. The morbid effects upon the fetus of modern obstetric practice must constantly be balanced against the undoubted rapid fall in mortality. With increasing vigilance of detection and improved treatment we have, as yet, no evidence that the "boom" of jaundiced babies has produced significant long-term effects on our population. 0 B EDEN Royal Hospital for Sick Children, Edinburgh Fden, 0 B, Revolta, A D, and Adjei, S K, British Medical Journal, 1974, 3, 573.
Computers and privacy
SIR,-Your leading article on this subject (24 January, p 178) is of particular interest to this practice. Since August 1975 we have been using a computer to maintain our medical records in total. We are particularly concerned with confidentiality and your last paragraph sums up our conclusions exactly. Each doctor has a unique secret password into the system. We also have a "p p" password which we release to our medical secretaries so as to allow them access to the records.
462
BRITISH MEDICAL JOURNAL
The reception staff have their own password, requested. These include diet and nutrition which allows access only to the patient's (including alcohol), air pollution, water polluidentification details and to repeat medication tion, and urban planning. details. These passwords can be altered when The subcommittee would be pleased to have we wish. observations in writing, preferably by 28 We have the facility to mark a record on the February. These should be sent to me: computer to allow access to read (but not to Dr A W McIntosh, c/o Executive Secretary, alter) to our nurses and health visitors. There Central Committee for Community Medicine, is a facility to suppress information that allows BMA House, Tavistock Square, London access only to the doctor who records the WC1H 9JP. information. This information can never be A W MCINTOSH Deputy Chairman, printed out or produced on microfilm. The Central Committee for Community Medicine staff of the Exeter Computer Project are all employees of the area health authority and are London WCI bound by the same code of ethics as we are. In fact they have no access to our records unless we give them our passwords. In short, our level of confidentiality is as secure as ever and if it were not for the continued presence of the medical envelope in the filing cabinet we could truthfully state that it had improved. J F SIDEBOTHAM G WARD J H BRADSHAW-SMITH J G PEGG J T ACKROYD Ottery St Mary, Devon
Clinical or administrative postal addresses ? SIR,-Why is it that health authorities insist on hospital notepaper having the name of the authority emblazoned at the top of the sheet ? The banner heading "Loamshire Area Health Authoritv (Teaching): Central Loamshire Health District" across the top of the page has no relevance whatever to a letter addressed from and requiring an answer to "The Royal Loamshire Infirmary." This practice not infrequently results in those who cannot be expected to know, and foreigners in particular, addressing their letters to "Loamshire Health Authority (Teaching): Central Loamshire Health District" and that letter finding its way to the ivory tower headquarters of one or other of these authorities, with consequent delay and frustration. I suggest that planners and administrators of the DHSS should think again about this matter. T B BOULTON Association of Anaesthetists of Great Britain and Ireland, London WC1
Editor, Anaesthesia
Preventive medicine-House of Commons inquiry SIR,-The Social Services and Employment Subcommittee of the Expenditure Committee of the House of Commons is conducting an inquiry into preventive medicine and the BMA has been invited to give written evidence. An ad hoc subcommittee of the Executive of the Central Committee for Community Medicine has been formed to prepare this evidence, which will cover the generality of preventive medicine and its effect on the life and health of the nation. We would, therefore, welcome observations on the subject, which may be incorporated in the Association's evidence: (a) in general; (b) on specific aspects which the House of Commons has particularly
21 FEBRUARY 1976
ployment of a doctor's dependants contravenes [sic] the Equal Opportunities (Sexual Discrimination) Act 1975." He went on to say that "a doctor's relatives are not precluded from the [ancillary staff] scheme by reason of their sex or marital status, but because of: (a) financial dependence on the doctor; and (b) live in his' residence." He referred us to paragraph 80.1 of the Statement of Fees and Allowances. Naturally we do not accept either his interpretation of the exclusion clause or of the new Act. I too work in my husband's practice and have done so since before 1966. As I work longer hours than Mrs Glanvill it is possible to compute our deficit to a figure even greater Consultants' ballot than hers. In my view this is a very strong argument in reply to the DHSS who have SIR,-At a recent meeting of the Rochdale stated in correspondence with me that the Area Health Authority Senior Medical Staff country cannot afford to meet such "nonCommittee the BMA's "A Ballot of Con- essential public expenditure." Should the sultants" was briefly discussed. A strong feeling country's finances be supported by a total lack was expressed that yet again this document of integritv ? evidenced the gulf that existed between the JULIE STAFFORD members of the Council and the grassroots of Kirkby in Ashfield, Notts the Association. It appeared singularly inept to make resignation contingent upon the non-acceptance of the Goodman proposals. It was felt that there Pay-beds in NHS hospitals would be many consultants throughout the country who would share with the majority in SIR,-I would like to congratulate Mr N H Rochdale in doubting the adequacy of pro- Harris (7 February, p 344) on extracting, tection of the Goodman proposals but albeit grudgingly, an admission from the who would hesitate to accept that resignation Secretary of State for Social Services that the was an appropriate alternative. Such action removal of pay-teJs from NHS hospitals will should be considered only in support of clear not reduce the waiting lists she complains of positive proposals which provided adequate so bitterly. That the pay-bed issue has nothing safeguards advocated by our own negotiators to do with improving the standard of medical and not by a third party retained by a fourth! care for NHS patients I can demonstrate. The West Midlands Regional Health To have formulated the ballot in this fashion is likely to have weakened rather than Authority, the largest single authority in strengthened our negotiating position and England and Wales, reported on 31 December again raises doubts as to the knowledge and 1974 that there were 59 400 patients on the experience of our counsellors in the field of waiting list (the 1975 returns -are awaited). political and industrial dispute. It underlines Their statistical tables show, however, that out the lack of sensitivity in the Central Com- of this total 51 417 were waiting for a surgical mittee for Hospital Medical Services to the operation of one sort or another. Some have needs and feelings of the majority of con- to wait two years. In contrast the waiting list sultants. Had these been adequately appre- for general medicine was 214, and 169 of those ciated we would have had leadership to a clear belonged to one hospital group; out of the course and the direction of our undoubted remaining 21 groups, 14 had no general medical waiting lists at all. The waiting list for strength to a positive end. D H TEASDALE paediatrics in the whole region was 19. The Chairman, same report shows that out of the 17 508 beds DONALD S LYON available to NHS patients the average occuSecretary, pancy was only 12 653 or 7220),,. Therefore Senior Medical Staff Committee to increase the number of beds by adding in and 19 other signatories the pay-beds will only increase the number Birch Hill Hospital, standing idle and unoccupied. Rochdale, Lancs From the fact that 865 0, of the waiting list was confined to general surgery, ENT, orthopaedic and ophthalmic surgery, and gynaeDoctors' wives and the Sex cology it follows that the waiting list is due to Discrimination Act a shortage of operating theatres. It is the Health Departments who are responsible for SIR,-I was interested to see Mrs Mary J the waiting list problem and no one else. They Glanvill's letter (7 February, p 343). have failed to implement their building proOn 19 January my husband and his partner grammes over the past 20 years. As far as NHS submitted forms ANC 1, 2, and 3 to the patients are concerned the pay-bed issue is Nottingham Family Practitioner Committee, irrelevant. with a covering letter saying that both the F S A DORAN word and the letter of the Sex Discrimination Bromsgrove General Hospital, Worcs Bromsgrove, Act render the exclusion of related ancillary staff obsolete. They also pointed out that it is now an offence to persuade or coerce emFair allocation of resources ployers to breach the terms of the Act. The Administrator of Family Practitioner Services replied on 29 January that the con- SIR,-The paper by Mr J H Rickard (31 tents of the letter had been carefully considered January, p 299) is most welcome. Reorganisa"but it is not felt that the criteria for the em- tion of the Health Service has allowed the dis-
21 FEBRUARY 1976
weakness in any other muscle groups. Two separate Tensilon tests (10 mg edrophonium chloride) wvith saline control were performed in a double-blind manner. After the first injection of edrophonium chloride the ptosis improved greatly, and two days later with the second test the improvement was less marked. After the Tensilon tests all therapy was stopped and the patient referred to the late Professor Andrew Wilson, who suggested that this myasthenic syndrome might be related to the practolol. Electromyography revealed no abnormality, nor did it six months later, when the patient had been off all therapy. Investigations including ESR, haemoglobin, blood urea and electrolytes, thyroid function tests, and x-rays of the mediastinum revealed no abnormality. The myasthenic symptoms have not recurred following the second dose of edrophonium chloride, but because the patient's blood pressure rose after stopping the practolol he was restarted on spironolactone 100 mg daily and bendrofluazide 5 mg daily.
461
Dukes classification stage A is a tumour limited to the submucosa, B is with invasion through the muscularis without nodal metastasis, and C with spread to the nodes." With regard to group A and to some extent also to group B this seems to be wrong. In the original article' and later papers and monographs by Dukes2 3 the definitions given are: in group A cases the growth is limited to the rectal wall (also including cases infiltrating into but not outside the muscularis propria); in group B the growth has infiltrated into the perirectal tissue but has not reached the regional lymph nodes; and in group C there are metastases in the lymph nodes. These groups are well illustrated by Dukes in the original paper and later articles. As the Dukes classification for cancer of the large bowel is used world-wide it seems most important that workers in this field, in stating that this classification has been used, should adhere to the definition given by Dukes himself to ensure as strict comparability of material and results as possible.
As remission may occur in myasthenia gravis perhaps a three-year follow-up period is too short to be sure that relapse will not occur. However, as the principal adverse effects associated with the use of practolol affect the eyes, skin, aural and nasal mucous membranes, CLAS G LINDSTROM and mesentery (14 June, p 577) and we have seen no mention of a muscular syndrome, we University Department of Pathology, General Hospital, feel it worth alerting clinicians to the possibility Malmo, Sweden of this syndrome being associated with practolol. Dukes, C E, 7lournial of Pathology anzd Bacteriology, 1932, 35, 323. R OSBORNE HUGHES 2 Dukes, C E, 7ournzal of Pathology antid Bacteriology, F J ZACHARIAS 1940, 50, 527. 3
Clatterbridge Hospital, Bebington, Wirral, Merseyside
Dukes. C E, Cancer of the Rectumsz, p 66. Edinburgh and
London, Livingstone, 1960.
***Dr Lindstrom is quite right; we quoted a widely used American version of the Dukes classification which, as he points out, is An unnecessary risk to children inaccurate. We agree that the definitions originally proposed by Dukes should be SIR,-While I have considerable sympathy retained for international use.-ED, BMJ. with the general contention that children should remain in the back seat- (leading article, 24 January, p 180). in the present state of the law on seat belt equipment this may serve Folic acid deficiency during intensive actually to increase the incidence of death and therapy injury rather than reduce it. This arises because less than 1 of cars have seat belts in SIR,-We have followed the recent papers on the rear seat, since they are not a mandatory this subject1 2 and the ensuing correspondrequirement, and children between the ages of ence;-- with great interest. Ibbotson et a14 8 and 14 rarely use the child type of harness, point out that we did not state the exact type In these circumstances it is quite conceivable of intravenous nutrition in our paper" and so that it is safer to be in the front seat belted up we have now received our two cases. The first than in the back seat unbelted. patient, who had a short illness following While the article quoted some statistics, mitral valve replacement, received saline and these were not on a comparative basis. In par- dextrose only, while the second, who had ticular, the extent to which the front seat risk septicaemia and renal failure, received Aminois higher than that for the rear and the savings sol (without ethanol) for six days in his terlikely to be brought about by the wearing of minal illness. However, circulating megaloblasts seat belts in each location. It may be that an were seen as early as 24 hours after comexpansion of your analysis would indicate that mencing this treatment. There is no evidence mandatory fitment of belts to the rear seats is that either patient received ethanol. a more beneficial proposal. Although our two cases fi-t into the syndrome It continues to be important that new legis- of rapidly developing folate deficiency during lation is reasonably likely to bring about an intensive therapy, they showed in addition improvement just as the effectiveness of new extremely bizarre features (for example, medications should be proved. Otherwise the gigantoblasts, dyserythropoietic changes, frepublic is brought into increasing conflict with quent multinucleate cells, vacuolation) superthe police for no benefit. imposed on the more usual megaloblastic J S ANDERSON changes. These additional changes may have been due to factors such as infection, drugs, Chorley, Lancs uraemia, anoxia, etc, having a direct effect on erythropoiesis. On an historical note, Ibbotson et all inDukes classification of carcinoma of the ferred from our paper that the first description rectum of this bizarre megaloblastic and dyserythropoietic anaemia of rapid onset occurring in SIR,-In your leading article (13 December, seriously ill patients was that of Limarzi and p 605) entitled "Search for presymptomatic Levinson.7 In fact we attributed this to an large bowel cancer" it is stated that "on the earlier paper by Harvier and Mallarme pub-
lished in 1938. Unfortunately this date was misprinted as 1968 in the list of references. M SAARY Department of Haematology, St Bartholomew's Hospital, London EC1
A V HOFFBRAND Department of Haematology, Royal Free Hospital, London NW3
IWardrop, C A J, et al, Lancet, 1975, 2, 640. Ibbotson, R M, Colvin, B T, and Colvin, M P, British Medical Journal, 1975, 4, 145. Wardrop, C A J, et al, British Medical Journal, 1975, 4, 344. 4Ibbotson, R M, Colvin, B T, and Colvin, M P, British Medical Journal, 1975, 4, 522. 5 Colvin, B T, and Ibbotson, R M, Journal of Clinical Pathology, 1975, 28, 1007. 6 Saary, M, et al, Journal of Clinical Pathology, 1975, 28, 324. 7Limarzi, L R, and Levinson, S A, Archives of Pathology, 1943, 36, 127. Harvier, P, and Mallarme, J, Sang, 1938, 12, 883. 2
Neonatal jaundice in association with operative delivery
SIR,-I read with interest Professor E A Friedman and Mr M R Sachtleben's paper (24 January, p 198) and their suggestion that clinically undetectable focal haemorrhage secondary to instrumental delivery might be a major contributory factor in the rising incidence of neonatal jaundice. I would like, however, to bring to their attention our findings published in August 1974.' On analysis of the full-term infants admitted to the special care unit of the Simpson Memorial Maternity Pavilion, Edinburgh, for hyperbilirubinaemia we similarly found no clear relationship with oxytocin administration, but the Kielland forceps delivery rate for the group was twice the mean for the hospital over the same period. Our conclusion was that the cumulative effects of induction plus operative vaginal delivery even near term probably produces a number of neonates not totally prepared for extrauterine life. In particular their hepatic conjugating mechanism might remain untriggered. We felt that focal haemorrhage too small to be clinically detected was unlikely to elevate the serum bilirubin concentration to such levels. The morbid effects upon the fetus of modern obstetric practice must constantly be balanced against the undoubted rapid fall in mortality. With increasing vigilance of detection and improved treatment we have, as yet, no evidence that the "boom" of jaundiced babies has produced significant long-term effects on our population. 0 B EDEN Royal Hospital for Sick Children, Edinburgh Fden, 0 B, Revolta, A D, and Adjei, S K, British Medical Journal, 1974, 3, 573.
Computers and privacy
SIR,-Your leading article on this subject (24 January, p 178) is of particular interest to this practice. Since August 1975 we have been using a computer to maintain our medical records in total. We are particularly concerned with confidentiality and your last paragraph sums up our conclusions exactly. Each doctor has a unique secret password into the system. We also have a "p p" password which we release to our medical secretaries so as to allow them access to the records.
462
BRITISH MEDICAL JOURNAL
The reception staff have their own password, requested. These include diet and nutrition which allows access only to the patient's (including alcohol), air pollution, water polluidentification details and to repeat medication tion, and urban planning. details. These passwords can be altered when The subcommittee would be pleased to have we wish. observations in writing, preferably by 28 We have the facility to mark a record on the February. These should be sent to me: computer to allow access to read (but not to Dr A W McIntosh, c/o Executive Secretary, alter) to our nurses and health visitors. There Central Committee for Community Medicine, is a facility to suppress information that allows BMA House, Tavistock Square, London access only to the doctor who records the WC1H 9JP. information. This information can never be A W MCINTOSH Deputy Chairman, printed out or produced on microfilm. The Central Committee for Community Medicine staff of the Exeter Computer Project are all employees of the area health authority and are London WCI bound by the same code of ethics as we are. In fact they have no access to our records unless we give them our passwords. In short, our level of confidentiality is as secure as ever and if it were not for the continued presence of the medical envelope in the filing cabinet we could truthfully state that it had improved. J F SIDEBOTHAM G WARD J H BRADSHAW-SMITH J G PEGG J T ACKROYD Ottery St Mary, Devon
Clinical or administrative postal addresses ? SIR,-Why is it that health authorities insist on hospital notepaper having the name of the authority emblazoned at the top of the sheet ? The banner heading "Loamshire Area Health Authoritv (Teaching): Central Loamshire Health District" across the top of the page has no relevance whatever to a letter addressed from and requiring an answer to "The Royal Loamshire Infirmary." This practice not infrequently results in those who cannot be expected to know, and foreigners in particular, addressing their letters to "Loamshire Health Authority (Teaching): Central Loamshire Health District" and that letter finding its way to the ivory tower headquarters of one or other of these authorities, with consequent delay and frustration. I suggest that planners and administrators of the DHSS should think again about this matter. T B BOULTON Association of Anaesthetists of Great Britain and Ireland, London WC1
Editor, Anaesthesia
Preventive medicine-House of Commons inquiry SIR,-The Social Services and Employment Subcommittee of the Expenditure Committee of the House of Commons is conducting an inquiry into preventive medicine and the BMA has been invited to give written evidence. An ad hoc subcommittee of the Executive of the Central Committee for Community Medicine has been formed to prepare this evidence, which will cover the generality of preventive medicine and its effect on the life and health of the nation. We would, therefore, welcome observations on the subject, which may be incorporated in the Association's evidence: (a) in general; (b) on specific aspects which the House of Commons has particularly
21 FEBRUARY 1976
ployment of a doctor's dependants contravenes [sic] the Equal Opportunities (Sexual Discrimination) Act 1975." He went on to say that "a doctor's relatives are not precluded from the [ancillary staff] scheme by reason of their sex or marital status, but because of: (a) financial dependence on the doctor; and (b) live in his' residence." He referred us to paragraph 80.1 of the Statement of Fees and Allowances. Naturally we do not accept either his interpretation of the exclusion clause or of the new Act. I too work in my husband's practice and have done so since before 1966. As I work longer hours than Mrs Glanvill it is possible to compute our deficit to a figure even greater Consultants' ballot than hers. In my view this is a very strong argument in reply to the DHSS who have SIR,-At a recent meeting of the Rochdale stated in correspondence with me that the Area Health Authority Senior Medical Staff country cannot afford to meet such "nonCommittee the BMA's "A Ballot of Con- essential public expenditure." Should the sultants" was briefly discussed. A strong feeling country's finances be supported by a total lack was expressed that yet again this document of integritv ? evidenced the gulf that existed between the JULIE STAFFORD members of the Council and the grassroots of Kirkby in Ashfield, Notts the Association. It appeared singularly inept to make resignation contingent upon the non-acceptance of the Goodman proposals. It was felt that there Pay-beds in NHS hospitals would be many consultants throughout the country who would share with the majority in SIR,-I would like to congratulate Mr N H Rochdale in doubting the adequacy of pro- Harris (7 February, p 344) on extracting, tection of the Goodman proposals but albeit grudgingly, an admission from the who would hesitate to accept that resignation Secretary of State for Social Services that the was an appropriate alternative. Such action removal of pay-teJs from NHS hospitals will should be considered only in support of clear not reduce the waiting lists she complains of positive proposals which provided adequate so bitterly. That the pay-bed issue has nothing safeguards advocated by our own negotiators to do with improving the standard of medical and not by a third party retained by a fourth! care for NHS patients I can demonstrate. The West Midlands Regional Health To have formulated the ballot in this fashion is likely to have weakened rather than Authority, the largest single authority in strengthened our negotiating position and England and Wales, reported on 31 December again raises doubts as to the knowledge and 1974 that there were 59 400 patients on the experience of our counsellors in the field of waiting list (the 1975 returns -are awaited). political and industrial dispute. It underlines Their statistical tables show, however, that out the lack of sensitivity in the Central Com- of this total 51 417 were waiting for a surgical mittee for Hospital Medical Services to the operation of one sort or another. Some have needs and feelings of the majority of con- to wait two years. In contrast the waiting list sultants. Had these been adequately appre- for general medicine was 214, and 169 of those ciated we would have had leadership to a clear belonged to one hospital group; out of the course and the direction of our undoubted remaining 21 groups, 14 had no general medical waiting lists at all. The waiting list for strength to a positive end. D H TEASDALE paediatrics in the whole region was 19. The Chairman, same report shows that out of the 17 508 beds DONALD S LYON available to NHS patients the average occuSecretary, pancy was only 12 653 or 7220),,. Therefore Senior Medical Staff Committee to increase the number of beds by adding in and 19 other signatories the pay-beds will only increase the number Birch Hill Hospital, standing idle and unoccupied. Rochdale, Lancs From the fact that 865 0, of the waiting list was confined to general surgery, ENT, orthopaedic and ophthalmic surgery, and gynaeDoctors' wives and the Sex cology it follows that the waiting list is due to Discrimination Act a shortage of operating theatres. It is the Health Departments who are responsible for SIR,-I was interested to see Mrs Mary J the waiting list problem and no one else. They Glanvill's letter (7 February, p 343). have failed to implement their building proOn 19 January my husband and his partner grammes over the past 20 years. As far as NHS submitted forms ANC 1, 2, and 3 to the patients are concerned the pay-bed issue is Nottingham Family Practitioner Committee, irrelevant. with a covering letter saying that both the F S A DORAN word and the letter of the Sex Discrimination Bromsgrove General Hospital, Worcs Bromsgrove, Act render the exclusion of related ancillary staff obsolete. They also pointed out that it is now an offence to persuade or coerce emFair allocation of resources ployers to breach the terms of the Act. The Administrator of Family Practitioner Services replied on 29 January that the con- SIR,-The paper by Mr J H Rickard (31 tents of the letter had been carefully considered January, p 299) is most welcome. Reorganisa"but it is not felt that the criteria for the em- tion of the Health Service has allowed the dis-
